The Role of Counselling on the Mental Health of Survivors of Extrajudicial Executions: A Case of Mathare Informal Settlement of Nairobi

I. INTRODUCTION

One of the globally acclaimed barometers for assessing how civilized and politically developed a society is, includes its capacity to protect and safeguard people's inalienable and fundamental rights. However, in several countries worldwide, extrajudicial executions (EJE) have been at the forefront of adversely affecting civilization by impacting human rights, especially violating the right to life (Aceves, 2018). Extrajudicial executions are defined as killings, which can rationally be presumed to be generated by a policy at any government level for the eradication of specific individuals as a substitution for arresting them and bringing them to justice (Amnesty International, 2020).

In Kenya, the evidence of extrajudicial executions is somewhat overwhelming. It has been documented by numerous entities, including the media, the Kenya National Commission on Human Rights (KNCHR), the Human Rights Watch (HRW), Community Justice Centres under the umbrella of the Police Reform Working Group (PRWG) and Missing Voices Kenya. However, despite the wave of extrajudicial killings that has been witnessed throughout the country, Mathare remains one of the most impacted by the killings. In Mathare, young males are constantly executed in the name of ethnic politics and violence. Besides, in these killings, Jones et al. (2016) stress that 'bonokos,' a common term for weapons placed next to the victim's body after the shooting by the police, are often used as justifications for the executions. The reality in Mathare Informal Settlement, therefore, entails the incessant violence enacted upon the young male population, but the government and the society neglect the existence of such an issue.

According to a study carried out between 2013 and 2015, Mathare had over 800 extrajudicial cases within this period (MSJC, 2015). An evaluation of these cases shows that the Mathare extrajudicial executions victims' average age is 20 years, with most victims being male. The extrajudicial executions adversely impact the survivors, family members, witnesses, and the community. As a result, the number of extrajudicial executions in Mathare continues to escalate. Any survivors of these inhumane acts are constantly subjected to a myriad of issues, including feeling stigmatized, living in fear, depressed, traumatic scars, overwhelmed with psychological disorders and other mental issues. The proliferation brings about a need for a study focusing on solutions, particularly counselling, to the mental health complications that extrajudicial execution survivors experience.

1.1 Statement of the Problem

In the contemporary world, extrajudicial executions have become more rampant, and the issue has taken up an astronomic increase in numerous nations across the globe. In most nations, particularly Indonesia, the Philippines, and Nigeria, the issue of extrajudicial killings remains unsolved, for not only does it involve government apparatus but also the ordinary citizens' support of these killings (Jones et al., 2016). In Kenya, similar to other countries with cases of extrajudicial executions, despite the existence of an avalanche of extrajudicial killings by the police, the Kenyan authorities hardly investigate the security agencies for their conduct but instead regularly defend the security agencies and deny that this issue exists in the country (Human Rights Watch, 2016).

A glance through existing studies on the subject matter also indicated that despite the issue of extrajudicial execution being deeply embedded in the contemporary culture, especially in informal settlement areas, the topic remains understudied. In the Mathare context, existing studies on extrajudicial killings within the region primarily focus on police killings (Stapele, 2019) and the correlation between extrajudicial executions of young ghetto men and conceptions of citizenship (Stapele, 2016). As such, a research gap exists in that no studies are focusing on the role of counselling on the mental health of survivors of extrajudicial executions within the Mathare Informal Settlement region.

1.2 Objectives of the Study

The following objectives guided the study:

i. To examine the prevalence of mental illnesses and disturbances among the survivors of extrajudicial executions in Mathare Informal Settlement.

ii. To identify the key problems leading to mental health complications in Mathare Informal Settlement.

iii. To determine the contribution of counselling on the mental health of survivors of extrajudicial execution in Mathare Informal Settlement.

iv. To identify possible obstacles that prevent survivors of extrajudicial execution in Mathare Informal Settlement from accessing and utilizing counselling services.

II. LITERATURE REVIEW

This section is divided into two segments, the empirical review and the theoretical review. The empirical review segment provides a detailed evaluation of existing studies on the role of counselling on the mental health of extrajudicial execution survivors and discusses the identified literature gaps. The theoretical review discusses the theories that guided the study.

2.1 Empirical Review

The Prevalence of Mental Illnesses among Survivors of Extrajudicial Executions

According to the World Health Organization (WHO), approximately 10-20 percent of adolescents and children in the global context suffer from mental disorders (WHO, 2014). On the other hand, KNHCR (2011) projects the global estimates of individuals that will experience a mental health illness at 25 percent, with about 20 percent and 10 percent of patients and the general population respectively seeking primary care presenting with mental health disorder symptoms at any specific time. These mental health disorders comprise primary insomnia, panic disorder, obsessive and compulsive disorder, post-traumatic stress disorder, Alzheimer's and other dementias, alcohol and selected drug user disorders, epilepsy, schizophrenia, bipolar affective disorder, and unipolar depressive disorders. Regarding psychosis, Kiima and Jenkins (2012) asserted that there is a likely prevalence of the disorder in the country at an average of one percent of the Kenyan population. Nonetheless, the most often diagnosis of mental health disorders made in the Kenyan general hospital settings are anxiety and stress disorders, substance abuse, and depression (Kenya Mental Health Policy, 2015). As a result of the diversity of mental health disorders, at any specific time, there is a high likelihood of a member of one in every four families be suffering from a mental illness (KNHCR, 2011).

Besides, the prevalent onset of the disorders during the early years of development and its continued perseverance through adulthood remains a crucially significant concern. Of the mental disorders, however, attention deficit hyperactivity disorder (ADHD) is among the most prevalent mental illness among adolescents and children. Particularly, ADHD is reported to affect about five to seven percent of individuals under the age of eighteen years of age, in the international context, with its pervasiveness being higher in males than in females. However, despite that ADHD has a high prevalence rate, depression is reported to have the highest prevalence rate, affecting about 5.6 percent of the world's male population and 11.7 percent of the female population, making it the most common form of mental illness (WHO, 2017). Besides, this mental illness can adopt numerous forms such as seasonal affective, postpartum, psychotic, and major depression based on risk factors, symptoms, and causes. The third most prevalent mental disorder among adolescents and children, autism spectrum disorder (ASD), is said to affect about one percent of the global population, with males being five more times to develop the condition compared to the female population.

The prevalence of mental illnesses is higher among individuals exposed to any form of a traumatic event in comparison to those not exposed to such situations. Particularly, Knipscheer et al. (2020) assert that exposure to a potentially traumatic event results in the development of post-traumatic stress disorder (PTSD). The study further examined the lifetime prevalence of PTSD across numerous nations and discovered that the rates ranged from below one percent in Switzerland and Nigeria to about five to nine percent in Norway, the Netherlands, and the United States and as high as 37 percent in post-conflict nations, such as Cambodia, Algeria, and Liberia. These fluctuations in prevalence were primarily associated with the vulnerability conveyed in numerous socioeconomic country characteristics, type of event, the disparities in the levels of wealth, and the deviating risks of exposure to possibly traumatic incidents. Alternatively, in the study of PTSD and trauma exposure in young people, Lewis et al. (2019) posited that youths at greater risk of developing PTSD following exposure to a traumatic incident include those who were subjected to interpersonal types of index trauma, those living in disrupted or disadvantaged families, those with a history of psychopathology, those who have undergone previous victimisation, and girls. Nonetheless, despite the numerous factors that have a significant influence on the onset of PTSD among individuals exposed to possible traumatic incidents, Kessler et al. (2019) posit that the trauma type has the most substantial impact on the prevalence of PTSD among these populations.

The rate of mental illnesses is particularly high among individuals subjected to police harassment and killings and other forms of extrajudicial executions. Luitel et al. (2013) found that the prevalence of mental illnesses was higher for individuals who had witnessed the harassment of others, those who were exposed to others being killed, as well as those who got hurt in the process. For these people, the study ascertained that they had a higher likelihood of developing PTSD, depression, and anxiety symptoms compared to the rest of the population. Regarding police violence and its association with the prevalence of mental illnesses, DeVylder et al. (2018) observed that police violence posed a substantial risk to public mental health. The study established that exposure to physical violence at the hands of the police force generated great odds of subclinical psychotic experiences, suicide attempts, depression, and psychological distress.

In the Kenyan context, psychiatrists have established that approximately 25 percent of out-patients visiting hospitals in search of care suffer from a certain form of mental health condition, such as obsessive compulsive disorder, alcohol dependence, generalised anxiety disorder, panic disorder, post-traumatic stress disorder, or depression. Furthermore, in the in-patient context, the number of individuals with any form of mental health condition increases to approximately 40 percent of in-patient clients. Concerning depression, Kenya was ranked at position four in Africa, with 1.9 million people suffering from depression, followed by Major Depressive Disorders (MDD), this is according to (WHO 2014). Besides, the prevalence of mental health disorders is attributed to be higher for vulnerable groups such as elderly persons, survivors of violence, the unemployed, individuals living in difficult conditions or poverty, adolescents and children with disrupted upbringing, or those with a chronic or serious physical illness. From this perspective, the young extrajudicial survivors from Mathare Informal Settlement can be denoted as having a very high probability of suffering from mental illnesses, for they are among the vulnerable groups. Specifically, these young people are not only victims of an extreme form of violence (extrajudicial killings) but are also brought up in difficult conditions, thus making the prevalence of mental health disorders.

The Key Problems Leading to Mental Health Complications in Mathare Informal Settlement

People develop mental health complications due to a broad array of reasons. First, according to the World Health Organization, mental health and a diverse collection of mental disorders are influenced to a substantial extent by the physical, economic, and social environments in which individuals reside (WHO, 2014). Secondly, Walsh (2011) asserted that the significance of lifestyle factors is an underestimated factor in the prevalence of mental health complications. The study attributes lifestyle factors to contribute to various psychopathologies, to the optimization and preservation of cognitive functions, and to fostering social and individual wellbeing. In this context, an unhealthy lifestyle, which is commonplace in Mathare Informal Settlement, functions as a key problem resulting in the development and advancement of mental health complications.

In addition, the lack of mental healthcare literacy and the absence of awareness regarding the existence and prevalence of mental health disorders in informal settlements result in the development of mental health complications. Particularly, in typical African and Kenyan contexts, mental illnesses and mental health disorders are perceived as sorcery or witchcraft (Gikonyo, 2009; Hugo, 2011). Another study by Reid et al. (2014) discovered that most communities and families considered the onset of mental health disorders as a punishment from the 'gods' for immoral conduct by a family member. As a result of the perception of mental illnesses as a punishment for immoral behaviour, for the individual suffering from mental illness, a strong sense of self-esteem is essential for effective coping with the mental illness. For those with low self esteem, watching their families' breakdown and the blame for their mental disorder being shifted to the mothers further result in the development of mental health complications (Munika et al., 2018).

In other instances, the social environment within the Mathare Informal Settlement plays a vital role in the development of mental health complications among the youths. Specifically, Fisher et al. (2013) argue that the pre-natal experience and the mother's maternal health influence the mental wellbeing of young children. For areas such as the Mathare Informal Settlements, the mothers are exposed to poor health and nutrition, poor environmental conditions, highly demanding physical labour, stress, alcohol and drug misuse, and smoking, which increases the children's probability of developing mental health complications during their early and adolescent years. In addition, in a meta-analysis and systematic review on 17 studies, early childhood growth and maternal depression or the development of depressive symptoms uncovered that children born and brought up by depressed mothers had a significant risk of being stunted and underweight, which amplified their risk of being diagnosed with a mental illness in later life (Surkan et al., 2011). In the case of Mathare Informal Settlement, the likelihood of maternal depression or the development of depressive symptoms is quite high due to insufficient emotional and practical support, the subjection to intimate partner violence, having hostile in-laws, the lack of intimate partner support and empathy, being unmarried, being young, unintended pregnancies, and socio-economic disadvantage. As a result, the children born and brought up by such mothers have a high probability of manifesting mental health complications in their early and later lives.

Finally, the exposure of the Mathare Informal Settlement youths to environments that induce stress response contributes to an increased prevalence of mental health complications. A WHO (2014) report establishes that exposure to stress-inducing settings over a young person's life course leads to the accumulation of stress-related behavioural responses such as drug and alcohol abuse, which transform to drug or related dependency, which are categorized as mental disorders. Besides, the accumulation of these stress responses over time significantly affects the individuals' behavioural, physiological, psychosocial, and epigenetic attributes, which leads to the development of factors that most immediately affect a person's mental health (WHO, 2014). Therefore, the exposure to stressors at the Mathare Informal Settlement serves as an amplifier to the young persons' risk of developing mental health complications, for these stressors leave them vulnerable to acquiring these complications. However, the provision of counselling services can play a crucial role in the restoration or improvement of this population's mental health outcomes.

Counselling in Promoting the Mental Health of Extrajudicial Execution Survivors

Counselling is defined as a way of assisting individuals in solving their own interpersonal social, or emotional problems (Matliwala, 2017). From this perspective, counselling does not entail giving advice or solving the clients' problems on their behalf; however, it entails helping clients to gain more insight into the underlined issues and objectively solving the issues. The counsellor's responsibility, in this context, comprises of showing the client a different dimension of understanding a particular situation as well as enabling the client to know their weaknesses and strengths without any judgment. From the client's perspective, counselling provides them with an objective and supportive environment for the exploration of their problems as well as an avenue for the determination of alternative courses of action that might lead to problem-solving.

Besides, individuals seek counselling for diverse reasons, including an inability to change, where despite possessing a desire to change, they lack the personal insight or self-awareness to drive them to alter their behaviours or actions. Other individuals seek out counselling when they are concerned by physical symptoms that fail to respond to medical remedies or investigations. These psychosomatic issues may comprise stomach problems, tiredness, sleep disorders, tension headaches, skin problems, among other similarly debilitating symptoms. On the other hand, for other people, lack of direction or motivation, low self-esteem, lack of assertiveness, difficulties at work, or academic underachievement may be the driving force towards engaging in counselling sessions. Finally, other people's search for counselling help is grounded on feelings of worthlessness, anxiety troubles, addictions and phobias, and frequently the belief that the failure to address these issues may further worsen their conditions. Nonetheless, anxiety and depression are identified as the main issues that instigate the search for counselling help(Sharf, 2012).

Counselling plays a critical role in the enhancement of people's mental health and general wellbeing. There is a general understanding that problem-related to mental health could be handled in a counselling context. According to Sharma (2019), the purpose of counselling is to enhance the individual's positive personality development and growth, assist in conflict management, improve their relationships, help them in coping with situational crises such as prolonged medical illnesses, pain, or bereavement, assist in the reversal or modification of problem behaviours, eradicate negative symptoms such as depression or anxiety, and help in the treatment of mental, behavioural, or emotional dysfunctions. According to Wango (2015), the effectiveness of counselling really depends on the ability of the client to bring out the desired changes, harness their own potential, and address their issues with certainty.

However, different counselling approaches serve specific purposes in the improvement of a person's mental and general wellbeing. For instance, cognitive behavioural therapy (CBT) is employed in the identification and correction of irrational, irregular, and negative thoughts that may have become automatic due to repetition. Particularly, the CBT approach works by challenging an individual's ways of thinking and enabling them to generate more realistic and helpful thought patterns of treatment, thus making it effective in the treatment of post-traumatic stress disorder, body dysmorphic disorder, panic, and generalised anxiety disorder, and depression. Relaxation therapy is employed in dealing with stress as well as in the decrease of autonomic hyperactivity and anxiety. For the modification of unhelpful and harmful behaviours that a person may have, behavioural therapy is utilized. However, despite its effectiveness, a majority of persons with mental health complications rarely gain access to counselling services due to numerous barriers.

Possible Obstacles to the Extrajudicial Survivors' Access and Utilization of Counselling Services

There exist numerous probable obstacles that impede the access and utilization of counselling services by individuals with mental disorders. To begin with, the stigma and discrimination connected to mental illnesses are commonly suggested impediments to the search for and access to counselling services (Zartaloudi & Madianos, 2010). In psychiatry, stigma is denoted as the attitude of disapproval towards individuals diagnosed with mental illnesses (Zhang et al., 2020). Meyer and Ndetei (2015) state that there are three types of stigmas related to mentally ill individuals, which include label avoidance, self-stigma, and public stigma. The public stigma is the most impactful form of stigma for mentally ill persons, for it may result in other members of the society acting against the stereotyped individuals. As such, these pejorative attitudes induce society to distance themselves, reject, and fear individuals with mental complications. Consequently, for individuals with mental illnesses, social stigma results in decreased help seeking behaviour, shame, concealment of symptoms, lowered self-esteem, and diminished opportunities (Seacat, 2014). Moreover, these stigmatizing attitudes towards individuals with mental illnesses have been found to be prevalent and resulting in influenced subsequent treatment behaviours on a global scale (Henderson et al., 2013). In the Kenyan context, the stigma associated with mental illnesses influences not only people's help-seeking behaviours but also the health professionals' willingness to work in mental health settings. Marangu et al. (2014) assert that the discrimination and stigma linked to mental health disorders is the predominant factor that explains why only a few health professionals decide to work in mental health services. The outcome is a decrease in the number of counsellors, which limits the number of individuals that can gain access to counselling services.

Secondly, financial barriers also serve as a substantial impediment to the access and utilization of counselling services. Corburn and Kaanja (2016) argue that the cost of care has been among the most cited hindrances to mental health treatment, especially in informal settlements. Besides, the possession of health insurance, through the public or private sector, is a primary determinant of access and use of health services. As a result, individuals without health coverage have greater unmet needs, delay seeking care, and experience greater barriers to care. Similarly, for mental health illnesses, individuals without health insurance face impediments to accessing counselling services. In the Kenyan context, individuals with mental illnesses lack not only health insurance but also the funds to cater to their medical care. A study by Musyimi et al. (2017) found that most Kenyans lacked the resources to get to the hospitals as well as pay for their treatment. During the study, some of the subjects reported a lack of food at the time of the research and, as such, argued that they were required to earn money to feed themselves and their families instead of seeking treatment. Therefore, financial inadequacy can be cited as among the critical hindrances to the access and utilization of proper mental health care by Kenyans with mental illnesses.

Thirdly, the disintegrated organization of mental health services has been identified as a significant obstacle to the access and utilization of counselling services. In the Kenyan context, not only does the country lack a formal, sanctioned mental health policy but also sufficient facilities for the provision of high-quality mental health services. The lack of a formally endorsed mental health policy has significantly limited the mental health reform agenda within the nation (Marangu et al., 2014). As a result, the country only has a single well-known psychiatric hospital, the Mathari Hospital in Nairobi, which focuses on the provision of in-patient services for all mental health clients across the nation (Ndetei et al., 2008). On the other hand, the country lacks mental health care services at the community level as well as in primary care facilities. In addition, the healthcare facilities that offer mental health care services, comprising of the district and sub district hospitals, lack the capacity to deliver out-patient mental health care services at the community level (KNHCR, 2011). As a result, for people residing in rural areas or informal establishments such as the

Mathare Informal Settlement, gaining access to mental health services is almost impossible due to a lack of essential resources and knowledge of this facility.

Fourthly, the lack of prioritization of mental healthcare in Kenya also plays a vital role in individuals' access and utilization of counselling services. Prioritization of resource apportionment for mental healthcare in a country like Kenya is constantly a challenge due to competing for health priorities, including the increment of chronic ailments such as renal failure, cardiac diseases, and diabetes, and the prevalence of infectious diseases such as malaria and HIV (Ndetei et al., 2007). Particularly, the country's reforms have primarily focused on addressing and eradicating communicable diseases as well as making improvements with regard to maternal and child mortality. The resulting outcome has been a low budget priority and the receipt of little attention by the mental healthcare domain, which adversely affects the growth of this field and the availability of low resources in the treatment of mental disorders, thus affecting the access to mental health services within Kenya. Furthermore, deficiencies have surfaced in the delivery of mental healthcare within the Kenyan context, where the Kenyans' mental health needs exceed the available mental health services at all the healthcare services delivery system levels, creating a "treatment gap" where significant individuals with mental illnesses lack the proper treatment (KNHCR, 2011). Besides, on a global level, this "treatment gap," particularly in lower-middle- and low-income countries, is projected to be at 75 to 85 percent, which equates to about 8.5 million in Kenya that lack the access and utilization of the care they need. In addition, for persons with mental illnesses, access to proper care is impeded because their families and carers lack sufficient information and knowledge of how to cope with a relative's mental health disorder.

The existing "treatment gap" is further widened by the availability of a limited mental health workforce in Kenya. Marangu et al. (2014) state that the key challenge for mental healthcare within the country is the critical shortage, or in some regions, the total inadequacy of a professional mental health workforce. Specifically, the country only has 54 psychiatrists, ten medical social workers, 418 trained psychiatric nurses, and a limited number of psychologists obligated with catering to the mental healthcare needs of a population of approximately 43 million people, with about four percent of this population having a major mental disorder. Furthermore, the Kenyan health workers at all levels are associated with low degrees of mental health literacy, which further compounds the issue of lack of access to mental healthcare surfacing from shortages of the mental health workforce, thus serving as an obstacle to the access and utilization of mental healthcare by the individuals suffering from mental illnesses.

2.2 Theoretical Framework

The Psychodynamic Theory

The psychodynamic theory has its roots in the psychoanalytic practice and theories of Sigmund Freud (Freud, 1923). This theory concentrates on the certainty that a significant portion of our mental functioning is unconscious (Dryden & Mytton, 1999). Besides, this unconscious section of our mental functioning is attributed to contain feelings and thoughts as well as memories that we have repressed for the avoidance of the conflict and pain they might generate. This theory further asserts that despite this material being somewhat repressed, it continues to have an intense impact on individuals' feelings, thoughts, and behaviours. In addition to the unconscious concept, this theory is also founded on an understanding of the structure of human personality.

The psychodynamic theory is primarily rooted in the understanding that the threat of punishment from the Superego, when combined with the demands of the Id, creates a substantial pressure that generates anxiety (Hough, 2014). Freud (1923) considered the Superego as encompassing internalized moral precepts, ideals, and values gained from parental and other authority figures, especially around the age of three. The Id is identified as the most primitive component of the system, which remains present from birth, and as such, is recognized as the repository for everything that is inherited, instinctual, and fixed in an individual's makeup (Freud, 1923). Besides, the theory establishes that the conflict linked to an individual's wishes and external reality results in the stemming of defence mechanisms that protect them against tension and extreme discomfort. These defence mechanisms comprise displacement, regression, introjection, reaction formation, denial, rationalisation, projection, humour, and repression. However, the persistent and prolonged use of these mechanisms tends to be counter-productive in the long run, for they not only require substantial amounts of vigilance and energy but also result in the falsification of experiences and reality distortion (Hough, 2014).

This theory, however, is among the critiqued models based on its application to clinical practice. Fonagy and Target (2010) critique the theory as not logically connected to the psychoanalytic technique clinical theory, as inductive instead of deductive reasoning, as well as its Reconstructionist clinical stance. However, Fulmer (2018) posits that the contemporary psychodynamic theory has evolved from its psychoanalytic roots, making it the most versatile and inclusive school of thought accessible to therapists.

The modern psychodynamic theory is ideally conceptualized as a system. From this perspective, contrary to the conventional approach that perceives the theory as either limited to personality or therapeutic model, the contemporary approach views the theory as a versatile system that both explains and embraces irrationality. As a result, Shedler (2010) asserts that the theory has proven its efficacy for a diverse range of populations and conditions, including personality disorders, substance-related disorders, eating disorders, somatoform disorders, panic, anxiety, and depression. Its broad application, therefore, makes the theory significant for this study in the determination of the contribution of counselling in promoting the mental health of survivors of extrajudicial execution in Mathare Informal Settlement. Besides, the theory's capacity to propose origins and explanations of problems makes it efficient in the identification of the key problems leading to mental health complications in Mathare Informal Settlement.

III. METHODS

The study adopted an ex post facto research design. The selection of the ex post facto research design was because of its capacity to allow a researcher to obtain conclusions that are specific and relevant without interfering with the study population (Salkind, 2010). Besides, this design allowed for the fusion of both quantitative and qualitative data, hence providing a means of exhausting the extrajudicial executions subject matter.

The study was conducted in Mathare informal settlement of Nairobi in Nairobi County. The researcher purposefully selected Mathare informal settlement for the study because a majority of the area's residents were living under harsh living conditions; some got involved in violence; lacked employment, and hence profiling and killing of crime suspect by the police officers. Of the settlement residents, those identified as survivors of extrajudicial execution, those who had reported cases of extrajudicial executions at Mathare Social Justice Centre formed the target population.

The researcher utilized simple random sampling in the selection of the study participants. Only 40 individuals from the Mathare Social Justice Centre database and who were residents of Mathare Informal Settlement formed the sample size. Rashid and Azeem (2011) specified that for an experimental study, it is desirable to have a minimum of 15 study participants in each group. Thus, a total of 40 study participants from the Mathare Social Justice Centre database were considered a sufficient sample size for the determination of the role of counselling on the mental health among Mathare extrajudicial survivors. From the 40 study participants, 20 were assigned to the experimental group and 20 to the control group.

Additionally, the study used questionnaires in collecting data from the 40 respondents. However, before undertaking the research, the researcher partook in a pilot test where ten questionnaires were administered to the targeted population. After the pilot test, any areas that were identified as requiring amendment were rectified before the main study. Finally, the researcher utilized SPSS (statistical package for social sciences) for descriptive analysis (using measures of central tendency such as mean, mode, and median, as well as tables and frequencies).

IV. RESULTS AND DISCUSSION

The researcher administered 40 questionnaires to Mathare Informal Settlement residents. The 40 questionnaires were duly filled and returned to the questionnaire, hence achieving a 100 percent response rate, which was sufficient for analysis.

4.1 Demographic Information

Of the 40 respondents, 52.5% (21) were female, whereas 47.5% (19) were male. Of these respondents, 22 were aged between 18 and 28, 11 were between 28 and 39, and seven were 39 years and above. As such, a majority of the respondents (55%) were between the years of 18 and 28. Concerning residency, two had been residents of Mathare Informal Settlement for less than a year, three had stayed in Mathare for between one to four years, two between four and seven years, four between seven and ten years, and 29 had stayed in Mathare for ten years or more. The findings that most of the respondents (73%) had been Mathare residents for ten or more years increased the study reliability for these participants had a better knowledge of the occurrence of extrajudicial executions events within the area.

Moreover, when asked whether they had witnessed any extrajudicial execution occurrences, 29 of the 40 respondents answered yes, whereas 11 answered no. These figures show that the probability of Mathare residents witnessing extrajudicial executions was high, for 72% of the respondents had already witnessed such incidences. On the other hand, when asked whether they had been victims of any extrajudicial execution occurrences, 17 of the 40 respondents answered yes, whereas 23 answered no.

4.2 Prevalence of Mental Illnesses Among Extrajudicial Execution Survivors and Witnesses

In the evaluation of the prevalence of mental illnesses among extrajudicial execution survivors and witnesses, the study focused on anxiety, insomnia or sleep disorder, depression, panic disorder, alcohol and drug abuse, post-traumatic stress disorder (PTSD), and other forms of mental illnesses. Table 1 below shows the obtained results on the identified mental illnesses' prevalence among extrajudicial execution survivors and witnesses.

Table 1: Prevalence of Mental Illnesses Among Extrajudicial Execution Survivors

These findings inferred that exposure to extrajudicial executions resulted in the development of mental illnesses among the witnesses and survivors. Of these illnesses, anxiety, insomnia and other sleep disorders, and panic disorder were the most prevalent among this population, with approximately three-quarters of the extrajudicial execution survivors developing anxiety disorders. Alternatively, the least prevalent mental illness among extrajudicial execution survivors was depression.

4.3 Key Problems Leading to Mental Health Complications Among Survivors of Extrajudicial Executions in Mathare Informal Settlement

A WHO (2014) report posited that a diverse collection of mental disorders is influenced to a substantial extent by the physical, economic, and social environments in which individuals reside. In the Mathare Informal Settlement context, the current study found the physical environment as a substantial contributor to the development of mental health complications among extrajudicial execution survivors. The survivor' subjection to poor environmental conditions was recognised as the primary problem resulting in their development of mental health conditions. The study also attributed the survivors' being born to and brought up in a family exposed to a mental breakdown and in a hostile home to an increased probability of developing mental health complications. Other contributors to mental health complications among extrajudicial execution survivors comprised experiencing unhealthy lifestyles and poor health and nutrition at the settlement.

Additionally, the study found that the absence of awareness regarding the existence and prevalence of mental health disorders in Mathare Informal Settlement and lack of mental healthcare literacy among Mathare Informal Settlement residents resulted in an increased likelihood of mental health complications. Similarly, Hugo (2011) established that the lack of mental healthcare literacy and the absence of awareness regarding the existence and prevalence of mental health disorders in informal settlements resulted in the development of mental health complications. Other environmental and social problems increasing the survivors' probability of developing mental health complications encompassed found smoking, alcohol, drug misuse, and exposure to police brutality and killings in Mathare Informal Settlement. Therefore, in addition to the trauma associated with being exposed to police brutality and extrajudicial executions, physical, environmental, and social problems also led to the extrajudicial execution survivors' development of mental health complications.

4.4 The Impact of Counselling on the Mental Health of Survivors of Extrajudicial Execution

The study compared the data collected from the experimental and the control groups to determine the impact of counselling on the survivors' mental health. The experimental group comprised individuals who sought counselling services to improve their mental well-being. The control group encompassed respondents who had never received counselling services after witnessing and surviving an extrajudicial execution. After asking the experimental group the number of times they sought counselling to improve their mental health, the figure below was obtained.

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Figure 1 above indicates that the least number of times that respondents within the experimental group sought counselling services was twice, and the highest was ten, whereas a majority of them sought counselling six times for the improvement of their mental state.

Table 2: below shows a comparison between the experimental and control groups' results on the impact of counselling on the survivors' mental wellbeing.

Table 2: The Impact of Counselling on Mental Health

The experimental group reported higher degrees of and more positive impacts of counselling on their mental health in comparison to the controlled group, as indicated in the table above. The standard deviation for the experimental group was relatively small, inferring to a small convergence in the study participants' assessments. Contrarily, the standard deviation for the controlled group was somewhat large, especially in comparison to the experimental group's, indicating a significant variation in the respondents' assessments concerning the impact of counselling on mental health for Mathare Informal Settlement extrajudicial survivors and witnesses.

For the survivors who sought counselling, the services positively impacted their mental and general wellbeing in multiple ways. Firstly, counselling helped them address their traumatic exposures. Secondly, counselling provided them a supportive environment to objectively evaluate their mental state. Thirdly, counselling services contributed to the adoption of positive and constructive behaviours and enabled them to create a social support network. Finally, counselling empowered and restored them, promoted their psychological wellbeing, and enabled them to address alcohol and drug-related addictions, improve relationships and interactions with others, and achieve personality development and growth. Therefore, seeking counselling can be significantly beneficial for extrajudicial execution survivors. However, several obstacles may impede these individuals' access and using counselling survivors.

4.5 Possible Obstacles That Prevent Survivors of Extrajudicial Executions in Mathare Informal Settlement from Accessing and Utilizing Counselling Services

The study found four primary obstacles that impeded the extrajudicial execution survivors' access and utilization of counselling services. The stigma connected to psychological disorders was the first obstacle preventing extrajudicial execution survivors' access and use of counselling services. Meyer and Ndetei (2015) found three types of stigmas related to mentally ill persons: label avoidance, self-stigma, and public stigma. Of the three forms of stigma, the public stigma might be the most impactful for the extrajudicial execution survivors with mental illnesses. Public stigma may result in other members of the society acting against the stereotyped individuals by distancing themselves, rejecting, and fearing the persons with psychological disorders. The second obstacle comprised the discrimination of persons with mental illnesses at the Mathare Informal Settlement. Thus, in fear of being discriminated against, survivors of extrajudicial executions in Mathare avoided seeking counselling services to enhance their mental wellbeing after exposure to traumatic experiences.

The third obstacle consisted of financial barriers. Notably, a majority of Mathare Informal Settlement's extrajudicial execution survivors lacked the financial resources required to obtain quality counselling services. Corburn and Kaanja (2016) backed these findings by citing financial barriers as among the primary barriers preventing individuals from accessing counselling services in informal settlements.

The final obstacle to obtaining counselling services for Mathare Informal Settlement's extrajudicial execution survivors consisted of lack of mainstreaming of counselling services in Mathare, the lack of high quality mental health services at Mathare Informal Settlement, and the inadequacy of professional counsellors and mental health workforce. KNHCR (2011) posited that the aforementioned obstacles arose because Kenya, as a country, lacked mental health care services at the community level as well as in primary care facilities. Besides, the healthcare facilities that offer mental health care services, comprising of the district and sub-district hospitals, lack the capacity to deliver out-patient mental health care services at the community level. As a result, for people residing in Mathare Informal Settlement, gaining access to counselling was almost impossible. Therefore, there is a need to minimize stigmatization and discrimination of mentally ill persons and to eradicate financial barriers and lack of quality counselling services for improved access and use of counselling services by extrajudicial execution survivors at Mathare Informal Settlement.

V. CONCLUSION AND RECOMMENDATIONS

The study results established that all Mathare Informal Settlement residents who had either witnessed or been a victim of extrajudicial executions suffered from a broad array of mental health complications. The identified mental disorders comprised anxiety, depression, alcohol and drug abuse disorders, panic disorders, post-traumatic disorders, and other forms of mental illnesses. Of these illnesses, anxiety was identified as the most prevalent among Mathare Informal Settlement extrajudicial survivors. Besides exposure to extrajudicial executions, the study identified physical, economic, and social environments as either exacerbating or leading to the development of mental health complications among extrajudicial execution survivors and witnesses. Of the persons that developed mental health complications, the study found that those who sought counselling services obtained positive mental health and overall wellbeing changes. Particularly, counselling services helped extrajudicial execution survivors address the traumatic exposures, offered them a supportive environment to objectively evaluate their mental states, and assisted them to adopt positive and constructive behaviours. Consequently, counselling empowered them to address alcohol and drug addictions, form a survivor's social support network, improve their relationships and interactions, and achieve personal growth and development. However, despite the numerous benefits of counselling, a substantial number of the extrajudicial execution survivors at Mathare Informal Settlement lacked access to counselling services. The obstacles impeding their access to and utilization of counselling services consisted of financial barriers, the stigmatization and discrimination of mentally ill individuals, and the lack of quality counsellors and counselling services at the Mathare Informal Settlement as well as the rest of the country.

The study recommended the implementation of education, community sensitization and awareness programs, and facilities offering quality mental health care as capable of minimizing or eradicating the extrajudicial execution survivors' access to counselling services. Specifically, the Mathare Informal Settlement residents should be educated on the adverse impacts of exposure to extrajudicial executions on their mental health, how to use counselling to minimize some of the negative psychological effects, and the available mental health care facilities. The county and local government should consider providing these residents with community sensitization and awareness on the importance of counselling to break the existing stigma associated with mental illnesses and the ensuing discrimination, as well as encourage extrajudicial execution survivors to seek help. Besides, the government should consider increasing healthcare facilities that offer mental health care services, comprising of the district and sub-district hospitals, especially in informal settlements like Mathare, where there is a prevalence of extrajudicial executions cases. The government should also ensure the employment of a highly-skilled workforce with the ideal counselling competencies, skills, and knowledge for offering quality services to those in need and using counselling in improving the mental and general wellbeing of extrajudicial execution survivors and other individuals who undergo traumatic experiences.

VI. SUGGESTIONS FOR FUTURE STUDIES

This study employed ex post facto research, which may have produced a certain degree of bias because of the lack of statistical tests. Besides, the research method cannot verify or test the research problem statistically, thus bringing about accuracy and integrity concerns. As such, future studies on the role of counselling on the mental health of survivors of extrajudicial execution in Mathare Informal Settlement should consider using quantitative data and quantitative data analysis methods. Moreover, this study's sample was confined to Mathare Informal Settlement, which decreases its generalizability. For improved generalizability of the research findings, future studies on the subject matter should attempt to cover a larger target population, such as the entire Nairobi County.